As part of its commitment to improve patient quality of care, the AADA Board of Directors recently approved a Guidance Statement on Documentation of Patient Encounters and Procedures. The statement identifies elements that may be useful and relevant for patient care and should be included in the patient record. For patient encounters that include an evaluation and management component, AADA recommends that documentation include a reasonably clear explanation of the patient visit and a description of the assessment and plan or actions taken. Regular and clear documentation optimizes clinical care by providing an informative record of patient encounters and procedures. For procedures and surgeries, documentation should include the indication for the procedure, a description of the procedure, and post-operative patient reactions.

The guidance statement also suggests topics that can either be streamlined or omitted for documentation, helping to alleviate the administrative burdens of practices. AADA’s recommendations include omitting information that is neither obvious nor relevant to the current complaint, abbreviating common procedures, and avoiding variations in terminology for common procedures or surgeries.

The AADA maintains that needless complexity and length in chart documentation can hinder timely communication of information and make it difficult for a caregiver to extract pertinent information. To read the statement in its entirety, please click here.

September 2014 -- Pathology Services Bill Receives Amendatory Veto from the Governor; Heads Back to the General Assembly

IDS members are very concerned about a bill -- SB 1630 -- that would unfairly regulate billing for pathology services needed by physicians as part of the treatment of their patients. Governor Quinn issued an amendatory veto on this bill and sent it back to the General Assembly. IDS doctors are urging lawmakers to allow this bill to die so that interested parties can come to an agreement on the best way to proceed on this issue during the next session of the state legislature. CLICK HERE for more information about this and other IDS legislative activities.